Provider Demographics
NPI:1174516132
Name:JACKSON, ANDREW CRAIG (CRNA)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:CRAIG
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 FALLS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TODD
Mailing Address - State:NC
Mailing Address - Zip Code:28684-9219
Mailing Address - Country:US
Mailing Address - Phone:336-877-2047
Mailing Address - Fax:336-877-5545
Practice Address - Street 1:200 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640-9244
Practice Address - Country:US
Practice Address - Phone:336-846-0719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC085415367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8049903Medicaid
2628918Medicare Oscar/Certification